[Learning from Mistakes? - A Randomized Controlled Trial on the Acquisition of Knowledge about Clinical Communication Skills Using Positive vs. Mixed Therapy Models]. / Aus Fehlern wird man klug? ­ Eine randomisierte kontrollierte Studie zum Erwerb von Gesprächsführungswissen anhand positiver vs. gemischter Therapiemodelle.

OBJECTIVE: This study compares two types of therapeutic model videos: an ideal model and a model that shows mistakes. The idea is that the conscious perception of mistakes is more likely to help build a comprehensive understanding of clinical communication skills than an ideal model. METHODS: A total of n1=111 psychology students and n2=57 people from the general population were randomly assigned to one of two training conditions as part of an online study. While one group watched a short but competent conversation of a behavioral therapist in their training with a positive model video, the other group watched a mixed model video in their training that showed a therapist with mediocre competence. In both training videos, the positive or negative behavior was marked with written explanations. Before and after the training, the participants rated the competencies of a therapist in another interview situation using standardized scales. These competence ratings were compared with those of two clinical experts and thus provided an indicator of the participants' conceptual knowledge of competent interviewing. RESULTS: A series of ANCOVA models showed that the group that saw the mixed model video deviated significantly less from the experts after training than the group that saw the positive model video (ηp2=0.03-0.10). However, the group that watched the positive (vs. mixed) model video deviated more strongly from the expert judgments on two of three competence scales after the training than before (dPre-Post=0.78-0.82). DISCUSSION: Overall, the hypothesis that mixed models are advantageous was confirmed. The unexpected results in the group with the positive model video could be explained by the fact that they set an unrealistically high anchor to which the later behavior is compared. CONCLUSION: Mixed models may offer some advantage over positive models in imparting knowledge about professional communication, especially when the model videos contain behaviorally relevant explanations.

Exposure therapy for health anxiety: Effectiveness and response rates in routine care of an outpatient clinic.

OBJECTIVE: Many randomized controlled trials (RCTs) have demonstrated the efficacy and benefits of exposure therapy in the treatment of health anxiety. However, the application of these research results to routine care has not been considered sufficiently. The aim of this study is to analyze the effectiveness of exposure therapy in the routine treatment of health anxiety patients. METHOD: Data were available for 35 patients, who repeatedly filled in comprehensive general questionnaires, and those specific to health anxiety. RESULTS: The data analysis showed that health anxiety symptoms decreased significantly both posttreatment (Cohen's d = 0.97-1.00) and at follow-up (Cohen's d = 1.33-1.34). In addition, the scores of depressiveness, somatic symptoms, and psychological distress showed improvements with effect sizes of d = 0.35-0.51. Regarding the primary outcome measures for health anxiety, response rates were 51%-63%, and remission rates were 29%-43%. CONCLUSION: Exposure therapy is effective and sustainable regarding the treatment of health anxiety, even under naturalistic conditions, whereas response and remission rates are lower than for RCT.

What characterizes helpful personal practice in psychotherapy training? Results of an online survey.

BACKGROUND: Personal practice (PP) is often considered as a central component in psychotherapy training aiming to promote personal and therapeutic competences. However, its implementation varies considerably in practice. AIMS: The purpose of this exploratory study was to examine the current practice of PP regarding the frequency/occurrence and perceived usefulness/impairment of topics, techniques and effects, as well as its helpful characteristics in psychotherapy training. METHOD: 407 German psychotherapy trainees (214 cognitive behavioural therapy; 178 psychodynamic therapy) were surveyed online as to their current practice of PP. RESULTS: For trainees, personal and therapeutic related topics were discussed. Reflection techniques and self-experiential practice were among the most frequently reported strategies, while the fostering of personal and interpersonal competences was among the effects with the strongest occurrence. However, negative PP effects were recorded as well. Differences in PP practice emerged between therapeutic orientations. CONCLUSIONS: As certain techniques which are central to PP (e.g. self-experience) were also rarely or not used, and negative effects reported, its potential might not be fully utilized.

Differences in psychotherapy preferences between psychotherapy trainees and laypeople.

Despite increasing research on psychotherapy preferences, the preferences of psychotherapy trainees are largely unknown. Moreover, differences in preferences between trainees and their patients could (a) hinder symptom improvement and therapy success for patients and (b) represent significant obstacles in the early career and development of future therapists.We compared the preferences of n = 466 psychotherapy trainees to those of n = 969 laypersons using the Cooper-Norcross Inventory of Preferences. Moreover, we compared preferences between trainees in cognitive-behavioural therapy (CBT) and psychodynamic trainees.We found significant differences between both samples in 13 of 18 items, and three of four subscales. Psychotherapy trainees preferred less therapist directiveness (d = 0.58), more emotional intensity (d = 0.74), as well as more focused challenge (d = 0.35) than laypeople. CBT trainees preferred more therapist directiveness (d = 2.00), less emotional intensity (d = 0.51), more present orientation (d = 0.76) and more focused challenge (d = 0.33) than trainees in psychodynamic/psychoanalytic therapy.Overall, the results underline the importance of implementing preference assessment and discussion during psychotherapy training. Moreover, therapists of different orientations seem to cover a large range of preferences for patients, in order to choose the right fit.

Group cohesion in group-based personal practice.

BACKGROUND: Personal practice (PP) is an integral component of many psychotherapy training programmes. It aims to promote personal and professional growth and is often conducted in a group format (g-PP). Group cohesion is one of the most researched mechanisms in group psychotherapy, but has rarely been studied in the context of g-PP. AIMS AND METHOD: This exploratory study examines the associations between cohesion, satisfaction with g-PP, its impact on personal and professional development, and theoretical orientation in a sample of n = 329 German psychotherapy trainees. Cohesion was assessed with the group questionnaire (GQ-D; Positive Bonding, Positive Working, Negative Relationship). RESULTS: Overall, participants reported high levels of all outcome variables. Positive Bonding was the strongest predictor of satisfaction with g-PP (ß = 0.46, p<.001). While trainees in cognitive behaviour therapy reported significantly better cohesion scores (d≥0.31), trainees in psychodynamic therapy reported significantly higher satisfaction with g-PP and its impact on their developments (d≥0.30). CONCLUSIONS: Group cohesion appears to be an important factor in g-PP that should be actively promoted by group leaders. However, longitudinal study designs are needed to better understand the emergence of cohesion in g-PP as well as potential moderating factors.

[Anxiety about Health of Patients Suffering from Epilepsy]. / Krankheitsängste bei Epilepsiepatient*innen.

BACKGROUND: The presence of somatic diseases makes diagnosis of health-related anxiety difficult. Studies have shown that a significant proportion of patients suffering from somatic diseases also suffer from illness anxiety. OBJECTIVE: Patients suffering from epilepsy were examined, for whom no data regarding their illness anxiety had previously been obtained. METHOD: 76 epileptics were analyzed regarding their psychological distress (Mini-SCL), fear of recurrence (PA-F) and hypochondriacal traits (MIHT). RESULTS: In general, epileptics experienced the same level of distress and fear in comparison to a norm sample. At the same time, 28% (overall distress) to 45% (anxiety) of the study participants were observed to have abnormal values. The fear of recurrence was low in comparison to other somatic diagnosis groups. Hypochondriac traits were seen in 7% (perceptive) to 13% (affective/behavioral) of the respondents. CONCLUSION: An increased awareness of illness anxiety in patients can help improve healthcare and quality of life of epileptics.

Recognizing obsessive-compulsive disorder: how suitable is the German Zohar-Fineberg obsessive-compulsive screen?

BACKGROUND: Despite the prevalence of obsessive-compulsive disorder (OCD), its precise identification remains challenging. With the Zohar-Fineberg Obsessive-Compulsive Screen (ZF-OCS; 5 or 6 items), a brief instrument is widely available mainly in English. As there is a lack of empirical studies on the ZF-OCS, the aim of the present study was to translate the items into German and investigate the instrument in a nonclinical sample. METHODS: In two consecutive online surveys, n = 304 and n = 51 students participated. Besides the ZF-OCS, they answered established measures on OCD, depression, health anxiety, general anxiety and health-related well-being. RESULTS: Whereas internal consistency was low (α = .53-.72; ω = .55-.69), retest reliability (rt1,t2 = .89) at two weeks was high. As expected, we found high correlations with other OCD instruments (r > .61; convergent validity), and significantly weaker correlations with measures of depression (r = .39), health anxiety (r = .29), and health-related well-being (r = -.28, divergent validity). Nonetheless, the correlations with general anxiety were somewhere in between (r = .52). CONCLUSIONS: Due to heterogeneous OCD subtypes, the ZF-OCS asks diverse questions which probably resulted in the present internal consistency. Nevertheless, the results on retest reliability and validity were promising. As for other OCD instruments, divergent validity regarding general anxiety seems problematic to establish. Even so, the ZF-OCS seems valuable for screening purposes, as it is short and easy to administer, and may facilitate initiating subsequent clinical assessment. Further studies should determine the instrument's diagnostic accuracy.

Research priorities set by people with OCD and OCD researchers: Do the commonalities outweigh the differences?

OBJECTIVE: In contrast to research agendas being predominantly set by scientists or funders, a collaborative approach was used to spot future goals for research on obsessive-compulsive disorder. METHODS: First, we conducted a meta-review and then compared the results of two online surveys with OCD professionals and patients on research priorities. The literature search was performed in three comprehensive databases, and ten research goals were extracted. Sixty-four patients and eight professionals responded to open questions on their five most important goals. Then, they ranked the ten aims extracted from the literature on a 6-point Likert scale. RESULTS: For patients and professionals, research on treatment gains that persist long-term was most important. Concerning the top five goals listed in an open format, for patients, development and maintenance of the disease was as important as psychotherapy and its efficacy. In contrast, for professionals, the efficacy and the optimization of psychotherapy were the far most important research goals. CONCLUSIONS: We proposed one possibility to involve patients in OCD research, and the multitude of answers presents a wealth of research ideas. PRACTICE IMPLICATIONS: Since consistent research involvement may contribute to its clinical impact, researchers are now invited to translate our findings into empirical studies.

Assessing therapist development: Reliability and validity of the Supervisee Levels Questionnaire (SLQ-R).

BACKGROUND: Therapist development is a crucial target for clinical training in order to ensure high-quality psychotherapy. A major challenge in examining therapeutic development is the assessment of developmental processes. The Supervisee Levels Questionnaire (SLQ-R) was analyzed in this study to examine its validity, reliability, and underlying dimensional structure. METHOD: Seven hundred and sixty therapists participated in an online survey concerning their current psychotherapy training. The factor structure as well as the validity of the SLQ-R were investigated using exploratory and confirmatory factor analysis. RESULTS: In line with the results of the exploratory factor analyses, a Bifactor ESEM (exploratory structural equation modeling) model with two factors and one global factor provided the best fit to the data. The two factors were labeled professional self-confidence and professional insecurity. CONCLUSION: Empirical support for reliability and validity of the new factor structure of the SLQ-R was found. The instrument is useful for assessing the therapist's developmental level.

The role of therapist and patient in-session behavior for treatment outcome in exposure-based cognitive behavioral therapy for panic disorder with agoraphobia.

OBJECTIVE: There is a very limited amount of research on the relationship between therapist and patient in-session behavior and treatment outcome in cognitive behavioral therapy (CBT) for panic disorder with agoraphobia (PD/AG). Additionally, the findings tend to be inconclusive. This study investigates the association between therapist competence, adherence, patient interpersonal behavior, and therapeutic alliance and outcome in a low-control CBT setting by using comprehensive measures. METHODS: Twenty-six patients with PD/AG received 12 sessions of exposure-based CBT. With regard to the outcome, treatments were classified either as problematic or nonproblematic by means of distinct criteria. Two raters evaluated the in-session behavior. RESULTS: Patient interpersonal behavior was significantly associated with outcome at follow-up (r = 0.49). At posttreatment, the correlation did not reach significance ( r = 0.34). Competence, adherence, and alliance were not outcome associated. CONCLUSION: The findings emphasize the need for therapists to pay particular attention to patients' interpersonal behavior during treatment.

The assessment of cognitive-behavioral therapy skills in patients diagnosed with health anxiety: Development and pilot study on an observer-based rating scale.

Cognitive-behavioral therapy is a highly effective treatment of health anxiety, but it remains unclear through which mechanisms treatment effects prevail. Some evidence suggests that patients acquire skills-understood as techniques helping them reach therapy goals-through psychotherapy. In the current study, an observer-based rating scale for the skills assessment of patients with health anxiety (SAPH) was developed and validated in a pilot study. Based on 177 videotapes, four independent raters evaluated the frequency of skills acquired during cognitive and exposure therapy among 66 patients diagnosed with health anxiety with the SAPH. Predictive validity was evaluated by the Yale-Brown Obsessive-Compulsive Scale for Hypochondriasis. The SAPH demonstrated good interrater reliability (ICC(1,2)  = .88, p < .001, 95% CI [.81, .92]) and internal consistency (α = .94). Although patient skills did not significantly increase during three sessions, they significantly predicted a reduction in health anxiety symptoms at the end of treatment (R2  = .35). Patients' skills are highly important within the treatment of health anxiety. By providing external ratings of patients' skills with good psychometric properties, our pilot data suggest that the SAPH may complement current tools for the assessment of skills, specifically in targeting health anxiety.

Strengthening competence of therapists-in-training in the treatment of health anxiety (hypochondriasis): Validation of the Assessment of Core CBT Skills (ACCS).

Although the observation and assessment of psychotherapeutic competences are central to training, supervision, patient care, quality control, and life-long practice, structured instruments are used only occasionally. In the current study, an observation-based tool for the Assessment of Core CBT Skills (ACCS) was translated into German and adapted, and its psychometric properties were pilot evaluated. Competence of therapists-in-training was assessed in a random sample of n = 30 videos on cognitive behavioural therapy including patients diagnosed with hypochondriasis. Two of three raters independently assessed the competences demonstrated in the entire, active treatment sessions (n = 60). In our sample, internal consistency was excellent, and interrater reliability was good. Convergent validity (Cognitive Therapy Scale) and discriminant validity (Helping Alliance Questionnaire) were within the expected ranges. The ACCS total score did not significantly predict the reduction of symptoms of hypochondriasis, and a one-factorial structure of the instrument was found. By providing multiple opportunities for feedback, self-reflection, and supervision, the ACCS may complement current tools for the assessment of psychotherapeutic competences and importantly support competence-based training and supervision.

Patients' and therapists' experiences of general change mechanisms during bug-in-the-eye and delayed video-based supervised cognitive-behavioral therapy. A randomized controlled trial.

OBJECTIVE: This secondary analysis of a randomized controlled trial investigated whether bug-in-the-eye (BITE) supervision (live computer-based supervision during a psychotherapy session) affects the manner in which patients and therapists experience general change mechanisms (GCMs) during cognitive-behavioral therapy (CBT). METHOD: A total of 23 therapists were randomized either to the BITE condition or the control condition (delayed video-based [DVB] supervision). After each session, both patients (BITE: n = 19; DVB: n = 23) and therapists (BITE: n = 11; DVB: n = 12) completed the Helping Alliance Questionnaire (HAQ) and the Bernese Post Session Report (BPSR). The HAQ total score and the 3 secondary factors of the BPSR (interpersonal experiences, intrapersonal experiences, problem actuation) functioned as GCMs. Multilevel models were performed. RESULTS: For patients, GCMs did not develop differently between BITE and DVB during CBT. Therapists rated the alliance as well as interpersonal and intrapersonal experiences not significantly different between BITE and DVB during CBT, but they perceived problem actuation to increase significantly more in BITE than in DVB (p < .05). CONCLUSION: BITE supervision might be helpful in encouraging CBT therapists to apply interventions, which focus on the activation of relevant problems and related emotions.

Standardized Patients in Clinical Psychology and Psychotherapy: a Scoping Review of Barriers and Facilitators for Implementation.

OBJECTIVES: The use of simulated and standardized patients (SP) is widely accepted in the medical field and, from there, is beginning to disseminate into clinical psychology and psychotherapy. The purpose of this study was therefore to systematically review barriers and facilitators that should be considered in the implementation of SP interventions specific to clinical psychology and psychotherapy. METHODS: Following current guidelines, a scoping review was conducted. The literature search focused on the MEDLINE, PsycINFO and Web of Science databases, including Dissertation Abstracts International. After screening for titles and abstracts, full texts were screened independently and in duplicate according to our inclusion criteria. For data extraction, a pre-defined form was piloted and used. Units of meaning with respect to barriers and facilitators were extracted and categorized inductively using content-analysis techniques. From the results, a matrix of interconnections and a network graph were compiled. RESULTS: The 41 included publications were mainly in the fields of psychiatry and mental health nursing, as well as in training and education. The detailed category system contrasts four supercategories, i.e., which organizational and economic aspects to consider, which persons to include as eligible SPs, how to develop adequate scenarios, and how to authentically and consistently portray mental health patients. CONCLUSIONS: Publications focused especially on the interrelation between authenticity and consistency of portrayals, on how to evoke empathy in learners, and on economic and training aspects. A variety of recommendations for implementing SP programs, from planning to training, monitoring, and debriefing, is provided, for example, ethical screening of and ongoing support for SPs.

Hypochondriasis Differs From Panic Disorder and Social Phobia: Specific Processes Identified Within Patient Groups.

Studies of the comorbidity of hypochondriasis have indicated high rates of cooccurrence with other anxiety disorders. In this study, the contrast among hypochondriasis, panic disorder, and social phobia was investigated using specific processes drawing on cognitive-perceptual models of hypochondriasis. Affective, behavioral, cognitive, and perceptual processes specific to hypochondriasis were assessed with 130 diagnosed participants based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria (66 with hypochondriasis, 32 with panic disorder, and 32 with social phobia). All processes specific to hypochondriasis were more intense for patients with hypochondriasis in contrast to those with panic disorder or social phobia (0.61 < d < 2.67). No differences were found between those with hypochondriasis with comorbid disorders and those without comorbid disorders. Perceptual processes were shown to best discriminate between patients with hypochondriasis and those with panic disorder.

Patient Characteristics and Patient Behavior as Predictors of Outcome in Cognitive Therapy and Exposure Therapy for Hypochondriasis.

OBJECTIVE: Psychotherapy for hypochondriasis has greatly improved over the last decades and cognitive-behavioral treatments are most promising. However, research on predictors of treatment outcome for hypochondriasis is rare. Possible predictors of treatment outcome in cognitive therapy (CT) and exposure therapy (ET) for hypochondriasis were investigated. METHOD: Characteristics and behaviors of 75 patients were considered as possible predictors: sociodemographic variables (sex, age, and cohabitation); psychopathology (pretreatment hypochondriacal symptoms, comorbid mental disorders, and levels of depression, anxiety, and somatic symptoms); and patient in-session interpersonal behavior. RESULTS: Severity of pretreatment hypochondriacal symptoms, comorbid mental disorders, and patient in-session interpersonal behavior were significant predictors in multiple hierarchical regression analyses. Interactions between the predictors and the treatment (CT or ET) were not found. CONCLUSIONS: In-session interpersonal behavior is an important predictor of outcome. Furthermore, there are no specific contraindications to treating hypochondriasis with CT or ET.

Competence feedback improves CBT competence in trainee therapists: A randomized controlled pilot study.

OBJECTIVE: The development and improvement of therapeutic competencies are central aims in psychotherapy training; however, little is known about which training interventions are suitable for the improvement of competencies. METHOD: In the current pilot study, the efficacy of feedback regarding therapeutic competencies was investigated in cognitive behavioural therapy (CBT). Totally 19 trainee therapists and 19 patients were allocated randomly to a competence feedback group (CFG) or control group (CG). Two experienced clinicians and feedback providers who were blind to the treatment conditions independently evaluated therapeutic competencies on the Cognitive Therapy Scale at five treatment times (i.e., at Sessions 1, 5, 9, 13, and 17). Whereas CFG and CG included regular supervision, only therapists in the CFG additionally received written qualitative and quantitative feedback regarding their demonstrated competencies in conducting CBT during treatment. RESULTS: We found a significant Time × Group interaction effect (η² = .09), which indicates a larger competence increase in the CFG in comparison to the CG. CONCLUSIONS: Competence feedback was demonstrated to be suitable for the improvement of therapeutic competencies in CBT. These findings may have important implications for psychotherapy training, clinical practice, and psychotherapy research. However, further research is necessary to ensure the replicability and generalizability of the findings.

Changes in Free Symptom Attributions in Hypochondriasis after Cognitive Therapy and Exposure Therapy.

BACKGROUND: Cognitive-behavioural therapy can change dysfunctional symptom attributions in patients with hypochondriasis. Past research has used forced-choice answer formats, such as questionnaires, to assess these misattributions; however, with this approach, idiosyncratic attributions cannot be assessed. Free associations are an important complement to existing approaches that assess symptom attributions. AIMS: With this study, we contribute to the current literature by using an open-response instrument to investigate changes in freely associated attributions after exposure therapy (ET) and cognitive therapy (CT) compared with a wait list (WL). METHOD: The current study is a re-examination of a formerly published randomized controlled trial (Weck, Neng, Richtberg, Jakob and Stangier, 2015) that investigated the effectiveness of CT and ET. Seventy-three patients with hypochondriasis were randomly assigned to CT, ET or a WL, and completed a 12-week treatment (or waiting period). Before and after the treatment or waiting period, patients completed an Attribution task in which they had to spontaneously attribute nine common bodily sensations to possible causes in an open-response format. RESULTS: Compared with the WL, both CT and ET reduced the frequency of somatic attributions regarding severe diseases (CT: Hedges's g = 1.12; ET: Hedges's g = 1.03) and increased the frequency of normalizing attributions (CT: Hedges's g = 1.17; ET: Hedges's g = 1.24). Only CT changed the attributions regarding moderate diseases (Hedges's g = 0.69). Changes in somatic attributions regarding mild diseases and psychological attributions were not observed. CONCLUSIONS: Both CT and ET are effective for treating freely associated misattributions in patients with hypochondriasis. This study supplements research that used a forced-choice assessment.

The Effects of Bug-in-the-Eye Supervision on Therapeutic Alliance and Therapist Competence in Cognitive-Behavioural Therapy: A Randomized Controlled Trial.

Live supervision enables a supervisor to have direct insight into the psychotherapeutic process and allows him or her to provide immediate feedback to the trainee. Therefore, live supervision might be superior to traditional supervisory formats that only allow for the provision of delayed feedback. When considering the different live supervision formats, bug-in-the-eye (BITE) supervision is particularly promising because of its improved and less invasive procedure. The current study compared the efficacy of BITE supervision with that of delayed video-based (DVB) supervision. In the present study, 23 therapists were randomly assigned to either the BITE supervision or DVB supervision groups. The participants were psychotherapy trainees who treated 42 patients (19 under BITE supervision and 23 under DVB supervision) over 25 sessions of cognitive-behavioural therapy. Two independent raters blind to the treatment conditions evaluated therapeutic alliance and therapist competence based on 195 videotapes. Therapeutic alliance was significantly stronger among the treatments conducted under BITE supervision than those conducted under DVB supervision. Moreover, a higher level of therapeutic competence was found in the BITE condition than in the DVB condition. However, no differences between supervision conditions were found when the results were controlled for the level of therapeutic alliance and therapist competence demonstrated in the first session. No differences were observed between the supervision conditions with respect to patient outcomes. There is evidence that BITE supervision is able to improve therapeutic alliance and therapist competence. However, these findings should be interpreted with caution because possible pre-treatment differences between therapists might explain the superiority of BITE supervision. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: BITE supervision positively influences the therapeutic alliance and therapeutic competencies during cognitive-behavioural therapy. A supervision format that more directly addresses therapeutic processes is more effective in improving those processes than an indirect supervision format. Pre-treatment differences between therapists might explain the superiority of BITE supervision. BITE supervision can be considered a safe intervention.